Care Home: 63-65 Bardsley Drive

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What the care home does well Prospective residents and their representatives have accurate information about the home in order that they can make an informed choice about moving to the home. The admission and assessment procedures ensure that an individuals needs are appropriately identified. The support and personal care that individuals receive is based on their specific needs set out in their care plans. Individuals rights to dignity and confidentiality is promoted. Individuals are able to exercise choice in their daily lives and maintain bonds with people who are significant to them. Individuals are supported to take part in social, cultural, religious and recreational activities and are encouraged to be involved in the running of the home and maintaining their daily living skills. The provision of activities within the community and at home are maintained. Individuals are offered and provided with a healthy diet. Individuals physical, emotional and health care needs are monitored and met. Individuals rights to choice and dignity is promoted. An open culture of raising complaints or concerns about the home is promoted. Procedures and policies are available within the home to promote the protection of individuals from harm and staff attend regular safeguarding vulnerable adults training to promote individuals rights to be protected from abuse or harm. The homes induction and mandatory training is consistent to ensure that individuals needs are appropriately and safely met by staff who have received appropriate training. The management and administration of the home is consistent and the home continues to be run in the best interests of the individuals and their views and opinions and those of others associated with the home are sought. What has improved since the last inspection? The monitoring of risk assessments has improved and is currently well managed to ensure the safety of individuals. Arrangements for the procedures and equipment to be made available for staff to undertake hand hygiene have been reviewed and the means for staff to wash and dry their hands have been made available in all appropriate places to minimise the risk of infection in the home.The homes recruitment practises have improved in order to ensure the protection and best interests of the individuals receiving care and accommodation at the home. The home have reviewed the arrangements for monitoring the quality of the service to ensure that the quality of care and processes of the home continue to be monitored and the findings documented and acted upon in order to promote the best interests of the individuals living at the home. What the care home could do better: The homes medication procedures must be strengthened to ensure that at all times medication is administered to all individuals in a safe and appropriate way. All areas of the home are generally clean. Improvements need to be made regarding staff awareness of the control of infection in the home. The maintenance and repairs in both homes needs to be improved to promote the safety and well being of individuals. Individuals welfare is promoted through the monitoring of health and safety in the home yet some shortfalls regarding the homes storage of foodstuffs and some of the organisationals policies and procedures need to be reviewed and strengthened to ensure the safety and well being of individuals receiving care and support in the home. Key inspection report Care homes for adults (18-65 years) Name: Address: 63-65 Bardsley Drive 63-65 Bardsley Drive Farnham Surrey GU9 8UQ     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Suzanne Magnier     Date: 0 7 0 4 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 32 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 32 Information about the care home Name of care home: Address: 63-65 Bardsley Drive 63-65 Bardsley Drive Farnham Surrey GU9 8UQ 01252727148 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): zoe.measures@tactsouth.org Affinity Trust Name of registered manager (if applicable) Mrs Yvette Barrett Type of registration: Number of places registered: care home 3 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users to be accommodated is 3 The registered provider may provide the following category of service only: Care home only (PC) to service users of the following gender; Either whose primary care needs on admission to the home are within the following category : Learning disability (LD) Date of last inspection Brief description of the care home 63/65 Bardsley Drive has been developed from two independent semi-detached houses to an integrated establishment whereby some of the facilities are shared. It provides accommodation for 3 adults with learning disabilities. The house is located in a quiet residential area and within walking distance of Farnham town centre. The home has its own transport to support individuals to access the wider community. There is off street parking at the front of the property, for two vehicles. The bedrooms are sited upstairs in both halves of the house. In addition, the ground Care Homes for Adults (18-65 years) Page 4 of 32 Over 65 0 3 2 7 0 7 2 0 0 9 Brief description of the care home floor area in both houses has a kitchen/diner and comfortable sitting room. The rear garden of the house is made up of one large patio area, with garden furniture. This is used as additional communal area, particularly in the summer months. Care Homes for Adults (18-65 years) Page 5 of 32 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The Quality rating for this service is 2 stars. This means that the people who use this service experience good quality outcomes. Following the previous key inspection on the 27th July 2009 the service has met all the requirements made. This visit to the registered care home was an unannounced Key Inspection and some additional standards were assessed and have been included within the report. Ms S Magnier Regulation Inspector carried out the inspection and the registered manager and the team leader represented the service. For the purpose of the report the individuals using the service are referred to as residents or individuals. The home had submitted the Annual Quality Assurance Assessment AQAA prior to the inspection, which was well written to inform the commission about the service and Care Homes for Adults (18-65 years) Page 6 of 32 some details of document have been added to the report. The inspector arrived at the service at 08.30 and was in the home for six hours. The inspection was a thorough look at how well the home is doing and took into account detailed information provided by the home and any information that the Care Quality Commission has received about the service since the last inspection. As part of the inspection the commission requested written surveys from people associated with the home. Two completed surveys were received from individuals which had been written on their behalf by staff and four written surveys were received from staff. The comments of the returned surveys have been included within the report. The inspector spent time talking to individuals and observing the staff members and residents in order to gain their views and opinions about the service. The inspector looked at how well the service was meeting standards and has in this report made judgements about the standard of the service. Documents sampled prior and during the inspection included the homes Statement of Purpose and Service User Guide, the Annual Quality Assurance Assessment (AQAA), care and person centred plans, risk assessments, medication procedures, staff recruitment files, a variety of training records, health and safety records and several of the organisations policies and procedures including the complaints and safeguarding procedures. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection and no safeguarding vulnerable adult alerts have been made following the previous inspection. From the evidence seen by the inspector and comments received, it is considered that the home continues to be able to provide a service that meets the needs of people who have diverse religious, racial or cultural needs. The final part of the inspection was spent giving feedback to the registered manager about the findings of the visit. Care Homes for Adults (18-65 years) Page 7 of 32 What the care home does well: What has improved since the last inspection? The monitoring of risk assessments has improved and is currently well managed to ensure the safety of individuals. Arrangements for the procedures and equipment to be made available for staff to undertake hand hygiene have been reviewed and the means for staff to wash and dry their hands have been made available in all appropriate places to minimise the risk of infection in the home. Care Homes for Adults (18-65 years) Page 8 of 32 The homes recruitment practises have improved in order to ensure the protection and best interests of the individuals receiving care and accommodation at the home. The home have reviewed the arrangements for monitoring the quality of the service to ensure that the quality of care and processes of the home continue to be monitored and the findings documented and acted upon in order to promote the best interests of the individuals living at the home. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 32 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 32 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective individuals and their representatives have accurate information about the home in order that they can make an informed choice about moving to the home. The admission and assessment procedures ensure that an individuals needs are appropriately identified. Evidence: The homes Statement of Purpose and Service user Guide included information about the aims and objectives of the service, staffing structures, facilities and care and social services to be offered in order that any prospective individual or their representative are informed of what services and facilities the home offers. The registered manager advised that all individuals living at the home have a written copy and an audio version of the Statement of Purpose and Service User Guide. The registered manager said that no individuals had been admitted to the home since the last inspection. There was a written policy and procedure within the home to support that an individuals care and support needs would be assessed and documented by a suitably qualified person to ensure that their specific requirements Care Homes for Adults (18-65 years) Page 11 of 32 Evidence: could be met by the homes staff before they are admitted to the home. Care Homes for Adults (18-65 years) Page 12 of 32 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The support and personal care that individuals receive is based on their specific needs set out in their care plans. Monitoring of risk assessments has improved and is currently well managed to ensure the safety of individuals. Peoples rights to dignity and confidentiality is promoted. Evidence: Following the previous inspection the homes staff have improved the standard of the residents care plans. The two care plans sampled were well documented to allow the reader to gain an overview of the individuals daily care and support needs, their medical, emotional, sensory, social and lifestyle preferences. The care plans indicated that all individuals have a key worker and there was evidence that the persons key worker had ongoing involvement in the persons plan of care and their welfare. It was observed that all the individuals responded favourably to staff during the inspection and that staff were instrumental in providing a predictable and structured daily routine for one individual who required this ongoing support due to the complexity of their needs to ensure their welfare and well being. Care Homes for Adults (18-65 years) Page 13 of 32 Evidence: The homes staff had commenced to introduce person centred plans which evidenced that residents were involved in the content of the plans and had been encouraged to maintain an interest and where possible sign the plans. The plans included photographs of exciting and meaningful events such as holidays and also goals which the individual would like to achieve. The homes staff promote individuals rights to have their opinions and concerns listened to and there was documented evidence to support that staff had and continue to promote independent advocacy both within and outside of the home should this be required by individuals in their lives. Following the previous inspection the home have significantly improved the documentation of risk assessments. A variety of risk assessments were sampled which reflected the current hazards in an individuals life, the actions that staff or the individuals representative should take in order to minimise the risk. The assessments indicated that they had been monitored to consistently promote the individuals safety and well being. It was observed that individuals were able to have choice and independence in their lives through staying in bed to have a lie, helping to make their own breakfasts, choosing what they wanted to do during the morning and being offered choices at the breakfast time in order to promote their rights to autonomy, independence and choice. Whilst touring the premises it was observed that there was awareness of individuals rights to confidentiality of their information as documentation was stored either in the individuals bedrooms or within the office in order to promote individuals rights to privacy and confidentiality. Care Homes for Adults (18-65 years) Page 14 of 32 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individuals are able to exercise choice in their daily lives and maintain bonds with people who are significant to them. Individuals are supported to take part in social, cultural, religious and recreational activities and are encouraged to be involved in the running of the home and maintaining their daily living skills. The provision of activities within the community and at home are maintained. Individuals are offered and provided with a healthy diet. Evidence: Throughout the inspection it was observed that individuals were comfortable and happy in their surroundings and the two staff were attentive to the needs of each individual. The AQAA advises that individuals require differing assistance and support with all Care Homes for Adults (18-65 years) Page 15 of 32 Evidence: activities and staff encourage individuals to gain new life skills where possible for example using public transport and cooking their own meals. One individual is currently being supported to pick a special recipe once a week and write out the ingredients required and is supported to the local shops to buy the ingredients to cook the meal, with staff support in the evening. One individual has pet guinea pigs that they look after and took great delight in showing the inspector their pets during the inspection. There was evidence that an activities plan was in place and included individual attending one to one sessions, supporting individuals at the gym, using the Wii fit, going bike riding, walking, visiting local day centres and also staying at home. There was photographic evidence to support that individuals enjoyed horse riding, visiting and working on a local farm, having planned holidays, going on shopping trips, ten pin bowling and visiting country parks. It was observed that within the care plans there was documented evidence that the skills and abilities of individuals were positively promoted by staff and the individuals abilities maintained. There was evidence to support that staff promoted individuals to gain new skills for example helping an individual to tie up their shoe laces, use tape recordings to support the person in their every day life, use reassuring prompts and have a structured and predictable routine which enabled individuals to feel reassured and secure. The home have purchased a small green house which one individual uses to grow tomatoes peppers and chillies. Individuals spoken with during the inspection said they liked the home and the staff and were happy. Both individuals knew who they could speak to if they felt unhappy. Two surveys written on behalf of individuals living in the home were returned to the commission and stated staff take me where I want to go. I feel safe. I like my home. I go out when I want with who I want to go with. What the home could do better is that we need more pictures, more holidays and to decorate the house. Whilst speaking with staff and looking at homes visitors book it was evident that individuals have limited involvement with their immediate family yet have strong links with the local community including neighbours and the local church where one individual attends regularly. Staff continue to support and encourage individuals to maintain contact and make new friends with people who are meaningful to the individuals. The inspector observed individuals being supported with their breakfasts where choices were offered and staff were attentive and respectful in the way each individual was supported to have their meals. The menu was observed to be flexible yet tailored to meet the specific needs and likes of individuals. The registered manager confirmed Care Homes for Adults (18-65 years) Page 16 of 32 Evidence: that referrals to the dietitian had been arranged for one individual and body weight charts were documented regularly to monitor individuals weight. Eating and drinking risk assessments were sampled and there was evidence to support that one individual had previously had specific input from the speech and language therapist regarding safe eating and drinking whilst having their drinks and meals. It was observed that in one individuals home that the table mats were of a poor quality and the registered manager arranged at the time of the inspection for the staff to support the individual to purchase new table mats for the dining table. The homes fridge and freezer were well stocked with fresh dairy products and fruit and vegetables were available. Records of fridge and freezer temperatures and food temperatures were available and well recorded. Care Homes for Adults (18-65 years) Page 17 of 32 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individuals physical, emotional and health care needs are monitored and met. Individuals rights to choice and dignity is promoted. The homes medication procedures must be strengthened to ensure that at all times medication is administered to all individuals in a safe and appropriate way. Evidence: The staff team provide gender based care for individuals who have requested a preference. It was observed that staff supported individuals in a sensitive way ensuring their privacy was respected when providing assistance with personal care. The individuals were well groomed and appropriately dressed on the day of the inspection and appeared happy with their surroundings and relaxed in the presence of the staff. The care plans and health action plans have been maintained and included records of attended health care appointments which included visits to the individuals general practitioner, chiropodists, dentists, dietitian referrals and and other specialist health care personnel appointments. Care Homes for Adults (18-65 years) Page 18 of 32 Evidence: The home have a medication policy and procedure. The medication cupboard is located in a safe and secure area and a monitored dosage system has been recently implemented. The medication administration charts were well documented and each individual had a separate section within the medication folder which included their photograph. Staff confirmed that no individuals receive controlled medicines and the use of homely remedies had been authorised by the individuals general practitioner. A staff member was observed administering one individuals medication without referring to the medication administration chart and when questioned by the inspector they explained that they knew what medication the individual was prescribed and therefore did not look. The inspector advised that this was not viewed as safe practise and the matter was brought to the registered managers attention during the inspection. The registered manager confirmed that she had spoken with the staff member and gave assurances that the incident was not general practise. This was supported by questioning other staff members who independently confirmed the appropriate procedures for administering medicines. A requirement has been made that at all times procedures regarding the safe administration of medicines must be maintained in order to ensure the safety of the individual receiving their prescribed medicines. It was confirmed that one individual continues to be supported to maintain their skill and ability to take their own medicines. A documented risk assessment and documented guidance for staff was available to support staff and the individual to continue with this safe level of independence. Care Homes for Adults (18-65 years) Page 19 of 32 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. An open culture of raising complaints or concerns about the home is promoted. Procedures and policies are available within the home to promote the protection of individuals from harm and staff attend regular safeguarding vulnerable adults training to promote individuals rights to be protected from abuse or harm. Evidence: Within the home there was a clear complaints policy and procedure, including a pictorial format, which was available for individuals or their representatives or other visitors in the home to see so that their views, opinions, concerns or complaints could be raised and acted upon. Staff confirmed that the homes culture is to promote individuals rights to make a complaint or raise concerns and these would be dealt with transparently, recorded and actions taken to resolve the complaint. Staff stated that they would be aware if individuals were unhappy or dissatisfied by observing a change in their general demeanour, communication and behaviour. Staff confirmed they would address the concerns with the registered manager or the team leader in order to support the individual and their rights to raise concerns. The AQAA advises that the home have not received any complaints since the last inspection and the complaints log sampled contained previous complaints which detailed the chronology of events for investigating complaints which had been resolved. The current local authority multi agency procedures for safeguarding adults were Care Homes for Adults (18-65 years) Page 20 of 32 Evidence: available to be sampled within the home. The registered manager confirmed that no safeguarding vulnerable adult referrals had been received or made to the local authority since the last inspection. The inspector sampled that the home has a flowchart which clearly documents the procedures for reporting any allegation of abuse. Staff independently advised the inspector, when questioned, about what constitutes abuse and what their actions would be to report any allegations which were in compliance with the local authority procedures. The registered manager confirmed that she facilitated staff safeguarding vulnerable adults training on an annual basis and the training matrix sampled indicated that staff attended safeguarding training on this basis. Whilst sampling the organisations policy and procedures related to complaints, safeguarding and whistle blowing several shortfalls were identified and have been addressed more fully in the final section of the report. The registered manager confirmed that the organisations director had been made aware of the shortfalls which were currently being addressed by the organisation. Care Homes for Adults (18-65 years) Page 21 of 32 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. All areas of the home are generally clean. Improvements need to be made regarding staff awareness of the control of infection in the home. The maintenance and repairs in both homes needs to be improved to promote the safety and well being of individuals. Evidence: During the tour of the premises the inspector observed that both homes had a homely atmosphere. The communal areas of both homes were observed to be spacious and individuals were observed to be comfortable and relaxed in their surroundings. One individual showed the inspector their bedroom which had been decorated to reflect their personality and contained a variety of personalised details and leisure items. The home was generally well maintained yet some shortfalls noted included that the kitchen tops in number 63 were in a poor condition and the grouting required renewing or replacing, the carpet by the back door required cleaning or replacing due to heavy stains. The staff advised that the hallways of number 63 had been redecorated and further decoration would be taking place including the bathroom and toilet whilst the individual who lives at the home was on holiday in the forthcoming months. Whilst touring the premises of number 65 it was noted that the upstairs Care Homes for Adults (18-65 years) Page 22 of 32 Evidence: landing carpet was frayed and was in need of replacing. It has been required that arrangements must be made that the general decoration and maintenance of both homes be undertaken which includes the replacement of the frayed carpet and kitchen work tops in order to ensure that individuals live in a safe and well maintained environment. The home was clean and orderly throughout however as previously recorded the fabric of both homes, in some areas, was in need of redecoration as it had a tired and worn appearance. It was observed that on arrival to the home a staff member came to open the door to the inspector yet had not removed their disposable gloves to open the door. The staff member confirmed that they were supporting an individual to get up and realised that they should have removed their gloves prior to coming downstairs. It was observed that the staff member was not wearing a protective apron and later during the morning the staff member was observed in the kitchen preparing an individuals cooked breakfast without wearing an apron. These shortfalls were addressed with the registered manager who confirmed that protective clothing was available in the home and it is the expectation that staff wear the clothing provided and adhere to the homes control of infection policy and procedures. It has been required arrangements must be made to remind staff of the importance of robust infection control measures in order to control the spread of infection in the home. Disposal of general and clinical waste was well managed. Following the previous inspection the requirement for the home to make arrangements for the procedures and equipment to be made available for staff to undertake hand hygiene have been reviewed and the means for staff to wash and dry their hands have been made available in all appropriate places to minimise the risk of infection in the home. It was observed that the radiators in the home were not covered and documented risk assessments for all individuals were in place. The changing needs of one individual was discussed with the registered manager and it has been advised that the vigilance regarding the current risk assessment needs to be maintained to reflect the individuals changing needs regarding their home and the hazards presented to them with in relation to the radiators not being covered. The back garden leading from both homes was well maintained and secure and remains accessible for individuals to use. Care Homes for Adults (18-65 years) Page 23 of 32 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes staff provide twenty four hour support to the individuals living at the home. The homes recruitment practises, induction and mandatory training is consistent to ensure that individuals needs are appropriately and safely met by staff who have received appropriate training. Evidence: The homes staff are currently supporting three individuals who have resided at the home for several years. Staff carry out all roles within the home, which include personal care, shopping, cooking, housekeeping and laundry as well as assisting individuals to social activities. On the day of the inspection there were three staff on duty and they were observed as skilled in supporting the individuals in their care and were knowledgeable regarding the specific needs of individuals to ensure their safety, well being and offer reassurance. The staff were observed to be thoughtful and thorough in explaining details of the day as there had been changes in one individuals programme due to the Easter holidays and offering the reassurance in order that the individual knew what was going to happen. The home has a recruitment and selection policy, which incorporates equal opportunities. The inspector sampled a recruitment file of a staff member that had not Care Homes for Adults (18-65 years) Page 24 of 32 Evidence: yet been fully completed. The file contained evidence of a full application, professional references were being sought, a face to face interview had been conducted which included the participation of individuals at the home, photographic evidence of identity was available and Criminal Record Disclosures had been sought. It is considered that the home has met the previous requirement made at the last inspection and currently operates a policy and procedure for the save recruitment of staff in order to ensure the protection and best interests of the individuals receiving care and accommodation at the home. The staff training matrix was sampled and it was evidenced that staff receive the Skills for Care induction training and mandatory training which included basic food hygiene, first aid, fire safety and moving and handling training in order to ensure that staff have the skills and abilities to provide the care and support needed by the individuals living at the home. The AQAA advises that the organisation holds the Investors in People Award in recognition of staff development. Five staff surveys were received which included comments We give the service users the essential needs to give them a better quality of life and our team of staff work well together. We have a good staff team and we keep up to date with the policies and procedures and Health and Safety. We could do better with the maintenance which needs updating. We meet the service users individual needs by having enough staff and there are good work rotas for household jobs and the house are kept to high standard. The home needs a bit more decoration. The AQAA identifies that 90 of the staff have achieved their National Vocational Qualification Level 2 or above in social care. Care Homes for Adults (18-65 years) Page 25 of 32 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home is consistent and the home continues to be run in the best interests of the individuals and their views and opinions and those of others associated with the home are sought. Individuals welfare is promoted through monitoring of health and safety in the home yet some shortfalls regarding the homes storage of foodstuffs and some of the organisationals policies and procedures need to be reviewed and strengthened to ensure the ongoing safety and well being of individuals receiving care and support in the home. Evidence: The registered manager demonstrated a good working knowledge of the home and the specialist needs of the individuals during the inspection. There was evidence throughout the inspection that the registered manager is committed, with the staff team, in continuing to monitor and improve the standard of care and support provided to the individuals at Bardsley Drive. As documented within the report it was evident through observation that the pace of Care Homes for Adults (18-65 years) Page 26 of 32 Evidence: the home continues to be designed to meet the needs of the individuals who benefit from the 24 hour support provided by the staff who also have a good knowledge about the individuals and their day to day lives and preferences. Confirmation was seen that the home has sought individuals and their representatives views and opinions about the home through the Quality Assurance procedures and monthly reviews of the individuals care and support plans which were available to sample during the inspection and reflected favourably of the care and support received by individuals. It was observed that some food stored in the homes refrigerator was labelled and stored in compliance with food hygiene standards and food temperatures had been recorded to ensure as far as reasonably practicable the safety and well being of individuals. A shortfall was identified regarding appropriate storage of food in the home as one sponge cake was found on top of the fridge and another in a cupboard, a package of processed chicken roll and several yogurts in the fridge had expired the use by date. It has been required that arrangements must be made that the homes staff must ensure that all food is stored in the home in an appropriate manner in order to ensure the safety and well being of individuals living in the home. Accident and incident records were sampled and the registered manager confirmed their awareness of the reporting any incidences, without delay, to the commission under Regulation 37 notifications of any event that affects the well being and welfare of individuals in the home. Whilst sampling the organisations policy and procedures related to complaints, safeguarding and whistle blowing several shortfalls were identified and the registered manager confirmed that the organisations director had been made aware of the shortfalls which were currently being addressed by the organisation. It has been required that arrangements must be made that several of the organisations policies and procedures comply with recognised professional standards and are an accurate and clearly written document to inform staff of the appropriate actions to take in the course of their duties. Following the previous inspection a requirement was made that arrangements for the monitoring the quality of the service must be reviewed to ensure that any shortfalls are identified and dealt with in a timely manner in order to ensure and promote the best interest of individuals receiving care and accommodation in the home. It was confirmed with the registered manager and documents were sampled to support that Affinity Trust had reviewed the format of the visits, referred to by the commision as Care Homes for Adults (18-65 years) Page 27 of 32 Evidence: the Regulation 26 visits. These ensure that the quality of care and processes of the home continue to be monitored and the findings are documented and acted upon in order to ensure and promote the best interests of the individuals living at the home. Records indicated that servicing of fire equipment had taken place and health and safety checks had been undertaken and recorded and chemicals were stored in compliance with the current legislation. A current insurance indemnity certificate and the current certificate of registration of the home were sampled and displayed. Some adjustments to the homes certificate of registration were addressed with the inspector and will be actioned by the commission following the inspection. Care Homes for Adults (18-65 years) Page 28 of 32 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 29 of 32 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 20 13 Arrangements must be made that at all times safe administration of medicines procedures must be maintained. In order to ensure the safety of the individual receiving their prescribed medicines. 30/06/2010 2 30 23 Arrangements must be 31/08/2010 made to remind staff of the importance of robust infection control measures in the home. In order to control the spread of infection in the home. 3 40 13 Arrangements must be made that several of the organisations policies and procedures comply with recognised professional standards and are an accurate and clearly written documents. 31/08/2010 Care Homes for Adults (18-65 years) Page 30 of 32 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action To inform staff of the appropriate actions to take in the course of their duties. 4 42 13 Arrangements must be made that the homes staff must ensure that all food is stored in the home in an appropriate manner. In order to ensure the safety and well being of individuals living in the home. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 31/08/2010 Care Homes for Adults (18-65 years) Page 31 of 32 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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